§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. John M. Taylor.]
§ 10 pm
§ Mr. David Alton (Liverpool, Mossley Hill)
I am indebted to you, Mr. Speaker, for this opportunity to raise the manner in which the regrading of midwives has been undertaken. I intend to examine the particular problems that this has caused in the Merseyside area. I am pleased to see that the Minister of State, Department of Health, is in his place to reply to the debate. I am sure that he will not be offended if I say that it might have been more appropriate if his hon. Friend the Parliamentary Under-Secretary of State were present. I understand that she was born in the Oxford street maternity unit which serves much of Liverpool. I am also pleased to see in the House the official Opposition spokesman. Anyone reading the debate will realise that in an Adjournment debate it is not possible for all hon. Members who are present to take part. However, I am glad to see so much interest.
It is no bad thing to remind the House that 76 per cent. of us were brought safely into the world by midwives acting alone and assuming total responsibility for life and death decisions. Ministers are no exception, and while stridently asserting their claim that the National Health Service is safe in their hands they should pause to reflect that from the moment of birth many of us are safe in the hands of any one of the 32,000 members of the Royal College of Midwives.
I want to use my time today to do three things. First, I shall set out the background to the present crisis, then I shall rehearse the grievances and finally I shall explore some of the ways forward. For just over 30 years between 1870 and 1902 midwives waged a national campaign to see themselves established as a separate profession and to create better maternity facilities for women. Thirteen Bills were required to be laid before Parliament before their much-prized autonomy was finally conferred. It is that hard-fought-for professional standing that is at the heart of the present dispute, not an avaricious love of money.
The present Prime Minister established the pay review body for nurses, midwives, health visitors and the professions allied to medicine. In its third report, the review body conceded that the RCM had put forward a well argued case for a separate pay and grading structure for midwives. Unfortunately, both management and staff sides opposed any such development and midwives were simply lumped into the general regrading exercise. Only one of the eight seats for negotiators on the staff side is held by an RCM representative, so the unique and distinctive arguments of the midwives have been pushed to the margins and given a Cinderella status.
As recently as 30 November, in reply to a letter from me, the Under-Secretary of State was still hiding behind the fig leaf of an agreement. Although midwives were a party to that agreement, it was never directly discussed with their professional body on a bipartisan basis. Two days ago, in answer to a parliamentary question which I tabled, the Secretary of State said:I suspect that much of the sense of grievance felt by some midwives in Merseyside is caused by misunderstanding of the basis of the grading exercise which the Royal College of Midwives and other trades unions agreed to."—[Official Report, 5 December 1988; Vol. 143, c. 86.]
410 I repeat that midwives were never entirely happy about the basis on which the regrading exercise was begun, and as the row simmered over the summer period their unhappiness turned to anger and dismay. The other organisations which made up the staff side understandably concentrated on important issues such as the definition of supervision and continuing responsibility. The midwives were treated as an obscure minority interest.
What are the midwives' grievances? Guidance on prime care providers was given by the Department to general managers in May and July 1988. The original agreement made between staff and management stated that one of the criteria for being placed on scale E was a requirementto take responsibility as the prime care provider for one or a defined group of patients/mothers, in the hospital setting. He/she works with minimal supervision in the assessment of all relevant care needs, the development, implementation and evaluation of programmes of care. The post holder is able to supervise and teach junior staff including basic and/or post-basic students.Subsequently, in evidence to the pay review body on 5 January 1988, the staff stated in paragraph 4.3 thatthe definition of the prime care provider at Scale E(2) was intended to cover those nurses and midwives carrying high levels of responsibility in relation to patients, clients or mothers, but whose work is so organised that they do not normally take charge of a ward or supervise other staff. There is no dispute that such jobs should be graded on scale E rather than D because of the level of their direct care responsibilities.
When the Department's guidance to general managers was published, it sought first to limit and then to prevent the use of those criteria for midwives. It inserted double-talk in the form of an interpretative note, which was never agreed with staff, stating thatthis is a 24 hour responsibility even though delivery of care is assigned to another nurse or midwife when the prime care provider is off duty.Clearly, in the context of midwives dealing with women whose labour may be less than eight hours, let alone 24 hours, and who may be discharged within hours of being admitted to the hospital, this is a deliberate exclusion clause. Yet the mother will have been cared for by one midwife throughout, who will have to make critical life-or-death decisions and a series of crucial judgments. The midwife is unarguably a prime care provider.
The Department proceeded to compound its felony in supplementary management guidance which advised health authorities that the prime care provider criteria applied to a few authorities where primary nursing had been introduced. By implication, it did not include midwives. I hope that the Minister will confirm that health authorities may apply those criteria for midwives, and that he will arrange for written guidance to general managers clarifying this apparent misunderstanding and the 24-hour rule.
Another grievance concerns the lack of fairness and consistency applied to the regrading exercise. Why has one staff midwife in 10 in England and Wales been placed on scale D, but only one in 500 in Scotland? Why have half the staff midwives in Wales been placed on scale F, but only one in eight in England? Why have 25 per cent. of midwifery sisters in Scotland and England been placed on scale F, but only 8 per cent. in Wales? There are many examples of hospitals where all or virtually all the hospital-based midwifery sisters have been placed on scale F, while in some areas every midwifery sister has been placed on scale G. 411 Funding restrictions are given as the reason for not having graded in accordance with the agreed criteria. Perhaps when the Minister replies he will say what differences exist between the five districts in the Mersey region. Will he say what consideration has been given to the consequences for recruitment and retention of midwives in the Mersey region and when it will be possible for them to move to north Wales and have their clinical skills recognised by higher grades and salaries? The problem cannot be minimised in a profession that already has an 8 per cent. vacancy rate at the sister-midwife level and a 17 per cent. shortfall of sister midwives.
The Minister will no doubt state, as have his right hon. and hon. Friends, that the sheer size of the award should satisfy midwives. If he or representatives of the regional health authority had been present at a meeting that I addressed on 18 November at the Liverpool Institution, he would realise that the inconsistencies and confusion caused by the grading implementation have far outweighed any so-called benefits. The 130 midwives present at that meeting—even those who had benefited —signed a petition, which I subsequently presented to the House on 23 November, registering their unanimous dismay at the block grading, which they believe has been determined by cash constraints and not clinical considerations. In early day motion 79, my right hon. and hon. Friends and I emphasise our support for their case.
Midwives at that meeting gave an example of a midwife with 10 or 12 years' service who was still on E grade. She will remain there until she either votes with her feet to leave the area or decides to go back into general nursing or into health visiting. To get to G grade is a near impossibility. Some sisters of 30 years' standing are not on G grade. The midwives told us at that meeting about students cancelling places at training schools. Although in October the Department stated that nurses opting for midwifery training need not be worse off during their training, the ludicrous situation still applies that, once they complete their training, they will be forced to apply for posts at the lower grade D. What sort of incentive is that? No one with a mortgage will be able to afford to take that option, so expenditure on such training will be of no avail. Taxpayers' money will be used to train people who will not be able to afford to take up posts.
The Merseyside midwives gave an example of one woman who had trained another, yet the trainee had ended up on a higher grade than the trainer. One midwife said, "The Minister seemed to think that just because Lofty could deliver a baby on EastEnders anyone could do it," and that midwives' worth had effectively been downgraded. Experience in other countries shows that fewer midwives leads to more deliveries by doctors, more intervention and more caesarian deliveries—in other words, serious long-term shortages of midwives will be detrimental to care of mother and child and carry grave consequences for maternity services.
What needs to be done? It is no good the Minister simply telling us that midwives in Merseyside and elsewhere should appeal. For a start, in many authorities the watchdog is too closely identified with the burglar, with the appeals mechanism weighted in favour of the health authorities. It is also a gruesomely long drawn out process, the length of which will turn this issue into a running sore. Before they consider the appeals, the Minister needs to tell the House what instructions he will give health authorities over issues such as prime care 412 provider criteria and on what basis appeals are to be settled. Are they, for instance, to be heard against the agreed grading criteria, or will authorities be expected to apply management guidance which grossly distorts those agreed criteria? The Minister needs to say what funds will be available if authorities decide to set aside their earlier decisions.
The Government also need to change their attitude. They appear to believe that midwives do not understand the grading structure and that that is responsible for much of the unhappiness in the profession. As midwives see it, the problem is very much the other way around.
§ Mr. Nigel Spearing (Newham, South)
Does the hon. Gentleman agree that despite the 25 per cent. reduction in staff at Newham general hospital the midwives' diagnosis of the problem is virtually the same as the one that he is outlining, which, I dare say, is found throughout the country? It appears to the staff that the Department does not understand their job or profession.
§ Mr. Alton
I am grateful to the hon. Gentleman for that intervention. The Merseyside problem is a microcosm of the difficulties faced all over the country and experienced by hon. Members on both sides of the House.
It is important for us to recognise that midwives are not arguing that they should all be on the same grade. They believe that those midwives with identical responsibilities should be on the same grade. They cannot accept that it is right for an arbitrary distinction to be made between midwives doing precisely the same jobs. Many are on the sister scale, not because of supervisory duties but because of their clinical expertise and responsibilities. They will not accept being told that only a limited number of them can be paid on the scale appropriate to those skills and responsibilities because the regional health authority Will allow them only a limited number of posts at that grade. They strongly resent that, whether the district authority has selected certain midwives for the higher grade or whether they are all asked to compete for the limited number of scale G posts.
Similarly, those midwives working in hospitals in ante-natal and post-natal areas cannot understand why they should be graded on lower scales than their colleagues doing similar work but based in the community. Midwives working in the community have a minimum of scale G, yet the Health Department has been advising that, although scale G posts may be in such areas as delivery suites and special care baby units, lower scales are appropriate for those hospital-based midwives who have responsibilities similar to those of their community-based colleagues. That is clearly nonsense. Each and every midwife, wherever she works, is legally accountable as an individual for the decisions that she makes and the actions that she takes. Hospital-based midwives are making crucial decisions without reference to other midwives or doctors every working day. If those decisions turn out to be mistaken, the midwife is liable to be struck off the professional register and be unable to practise. Community midwives find those arbitrary distinctions just as difficult to understand or support as do hospital-based midwives.
What midwives such as Lorna Muirhead, a local RCM representative who organised the Liverpool meeting to which I referred, cannot understand is how a health department which supports integrated maternity services and therefore flexibility within maternity units and 413 flexibility between hospitals and the community can be seeking to enforce gradings which are having the effect of preventing that.
All concerned agree that the operation and extension of that flexibility is desirable and in the interests of mothers and babies alike. I hope that I have said enough for the Minister to realise that, on Merseyside and in the country at large, midwives feel a deep sense of grievance and that we owe it to them and to mothers-to-be to come up with something better than the present grading hotchpotch. I hope that the Minister understands that they and their professional body, the Royal College of Midwives, which has today met the Secretary of State, will be awaiting his reply tonight with hopeful anticipation.
§ The Minister of State, Department of Health (Mr. David Mellor)
I am grateful for the opportunity to set the record straight about the grading of midwives both nationally and in the Mersey region because the hon. Member for Liverpool, Mossley Hill (Mr. Alton) is only the last in a long, but perhaps not altogether distinguished, line of people who have said some pretty extraordinary things about this exercise.
Claims that the midwives have done badly out of this exercise quite simply do not stand up. This is the best deal ever for midwives and the biggest ever pay award for their profession, worth well over 20 per cent. on average. This award gives the profession the highest ever level of real terms pay, higher than the previous high point set by the Halsbury report in 1974 and the Clegg award in 1979. This is a larger award than that enjoyed by any other major staff group in the public sector this year. Midwives have done even better than nurses in the regrading exercise, which reflects their qualifications.
I should like to bring some figures into this debate that will demonstrate that. As I have said, the average pay award for midwives this year is over 20 per cent. and, for staff midwives, it is over 25 per cent. In each case, these figures are exclusive of the London supplements which will add another 5 per cent. to 9 per cent. for those individuals who work in midwifery in London. Staff midwives have done particularly well. Nine out of 10 have gone on to the higher grades with increases this year of around £2,000, a quite unprecedented sum. The bulk of staff midwives have gone on to scale E with basic pay now of £9,200 to £10,650 a year and almost £2,000 a year more than that in inner London. With additional payments for working unsocial hours and overtime, the average earnings on this scale are likely to rise to £12,500 in the country generally and to around £14,500 in inner London.
About one in eight staff midwives has been graded at F and received even larger increases of 40 to 45 per cent., an utterly unprecedented sum; that is to say, £2,900 to £3,900 this year. The hon. Member for Newham, South (Mr. Spearing) finds that funny, but he was a supine Back Bencher in the days when Labour Governments were cutting the real pay increases of nurses and midwives by 20 per cent.
The minority of staff midwives—about one in 10—who have gone on to the lowest grade of D have still received increases this year of 7 to 10 per cent. and have still seen 414 their pay go up in real terms by 30 per cent. since 1979, an arresting contrast with what happened in the preceding years.
Three out of four midwifery sisters have gone on to the higher grades and will receive increases of £2,000 to £3,000 this year. Their new scales are from £12,025 a year to £13,925 a year with additional payments for unsocial hours and overtime. Earnings for this grade are likely to rise to an average of £16,000 or almost £18,000 in inner London.
A minority of midwifery sisters who receive smaller increases this year will nevertheless have seen their pay go up by over one third in real terms since 1979. Midwives have gone into the higher grades in even larger numbers than nurses at both levels. This reflects the additional qualifications that midwives must have.
At staff midwife level, no fewer than 77 per cent. are on grade E, compared with 66 per cent. of staff nurses, and 12 per cent. have gone into grade F compared with 9 per cent. of staff nurses. As for midwifery sisters, 74 per cent. have gone into grade G compared with 58 per cent. of nursing sisters.
It is not true that midwives have been treated badly during the exercise. Indeed, the exercise will give the nursing profession the greatest shot in the arm that it has had since the National Health Service was founded.
§ Mr. Mellor
No, I shall not give way. If the Opposition want to debate the matter, they have their parliamentary time. I can assure them that my right hon. Friend the Secretary of State and I are only too willing to debate it at greater length, but this is not the occasion to do so. I want to get a few facts on the record in response to what the hon. Member for Mossley Hill said.
§ Mr. Mellor
I understand that there is some misunderstanding in certain quarters within the profession. That is inevitable when a major change is instigated by the unions concerned, which were pressing for regrading. They did not want an across-the-board pay increase. They wanted a regrading that gave nurses and midwives an incentive to stay in clinical medicine rather than go into administration to improve their lot. When half a million people are being regraded in six months—perhaps the most massive industrial relations exercise that has ever been undertaken in Britain—it is inevitable that there will be some misunderstanding. That is why I want to deal with some of the issues that have been misunderstood. A number of points arise from what the hon. Member for Mossley Hill has said.
We are talking about the greatest change in the way in which nurses and midwives are graded and paid in the history of the NHS. It is clear that some do not fully understand the thinking behind the change, and that is inevitable. We have a task before us to ensure that the reasons for the change are plainly understood. The old grading system was based on qualifications. Under the new structure, posts are graded on the basis of duties and responsibilities. In other words, the basis of grading has been overturned. It follows that some of the issues raised by the hon. Member for Mossley Hill, such as length of time in post and qualifications held, are not in themselves 415 factors that decide grading. That was commonly agreed after two and a half years of negotiations between unions and management.
§ Mr. Mellor
Midwives absolutely, yes. As usual, the hon. Gentleman is wrong on his facts. The Royal College of Midwives was a party to the agreement, along with the Royal College of Nursing. The colleges actively sought a regrading exercise and sought to persuade the Government that it was not sufficient to think in terms of pay increases. They argued that it was necessary to change the basis of grading, which was entirely archaic. A staff nurse was on one grade and a sister was on another. There was a low plateau of achievement in clinical medicine in terms of salaries and awards. It was time to do better, and I believe that history will show that that is what we have done.
Inevitably, there is dislocation. The unions and the royal colleges knew when they embarked on the exercise that the basis of the regrading structure made it certain that some who were similarly graded in the past would find themselves in different grades and receiving different pay increases. That was inherent in the scale of the change.
I appreciate that there are some concerns that are specific to midwives, and I am happy to address them. We know that midwives have long had the ambition that they should have a separate pay and grading structure. They have sought unsuccessfully to persuade the management side and the rest of the staff side of the nursing and midwifery staff negotiating council to accept that. They failed to impress the staff side and they took their case to the review body, which also rejected the idea that midwives, valued though they are—and they are valued enormously within the service—should have an entirely separate grading structure.
The review body is another innovation of this Administration. Needless to say, the Labour Government were always in far too much economic jeopardy ever to agree to allow anything so radical as nurses' and midwives' pay to be recommended by a wholly independent body, recommendations which the Government would accept unless there were exceptional reasons not to do so. It was an innovation of the Conservative Government in recognition of the services nurses and midwives give to the community, and in recognition also of the happier economic times that allow us to fund increases of a sort that could not have been contemplated previously.
In its fifth report, the review body said that the new structure, to which the Royal College of Midwives as part of the staff side agreed, wouldprovide a satisfactory basis on which to determine the grading of midwives, taking account of their training, qualifications and the particular responsibilities they carry.In determining that midwives should be on the same grading structure as nurses, we were acting on the clear endorsement of the independent review body, which has been established to consider those matters. I understand that the Royal College of Midwives remains attached to its opinions, notwithstanding the fact that it has, thus far, been unable to persuade anyone else, not least its colleagues on the union side, to join it on that point.
Of course, the vast majority of midwives have to undertake midwifery training after they have completed training as general nurses and some midwives say therefore that they should have a higher level of grading as soon as 416 they have qualified. The management side's view is that the minimum level for midwives should be D—the same as the minimum level for registered nurses although, of course, only a small minority—one in 10—of staff midwives actually start on D. Nothing in the analysis of midwifery posts that was carried out during the grading review indicated that newly qualified midwives were working in a significantly different way from newly qualified nurses. We have to accept that in the modern Health Service of today, with high technology medicine a commonplace, there are many sophisticated practitioners of the arts of nursing and midwifery. Midwives, although vital to the service, are only one of a range of groups that bring additional qualifications and specialisms to the Health Service and that are equally entitled to be graded under this new grading structure, with unprecedented levels of salary and prospects. A sister who was earning £96 a week maxim um less than 10 years ago under the benevolent rule of the Labour Government now stands to earn at least £270 a week and, usually, on higher grades, much more than £300 a week. We would hardly have dared in 1979 to have said that that would be the improved condition of nurses and midwives, but that is what we have achieved.
I conclude by dealing with the specific problems in Mersey. The hon. Gentleman very properly ranged more widely and I am glad to have had a chance to say something about the national picture. Turning to the outcome of the exercise in Mersey, the grading outcomes are very much in line with the national figures. A large majority of staff midwives and midwifery sisters have gone into the higher grades. That is hardly surprising because, of course, the exercise in Mersey has been carried out in line with the national guidelines. There are 190 different health districts in England and each of them is an independent decision-taker. It is inevitable that there will be differences between one district and another and the only alternative to that is for the man in Whitehall to do the whole job himself, which would lead to an equal range of protest, not more. I can imagine the outcry from the Opposition if there were more attempts by Whitehall to say that each district should come into line with another. We are caught in a Morton's fork. On the one hand, if we intervene too much we are criticised, and if we allow some districts to go their own way, we are criticised for that. It is a no-win situation and we must take much of the criticism with a substantial grain of salt. My hon. Friend the Parliamentary Under-Secretary of State for Health assures me that salt in excess is bad for health.
To the extent that the pattern of grading differs from that elsewhere, this is likely to be explained by the fact that, under the old grading system, there were 60 per cent. more midwifery sisters than staff midwives in Mersey. That compares with a national pattern where there were about 10 per cent. more midwifery sisters. That is good news for Mersey because it means that the number of experienced midwives in the region is somewhat higher than elsewhere. It also means that sisters in Mersey were doing some of the jobs that staff midwives were doing elsewhere and vice versa, and this will, very properly, be reflected in the grading outcome, which analyses existing jobs and not individuals.
The newly appointed regional nursing officer in Mersey is keen to develop the educational strategies for midwives in the Mersey region. Plans are in hand for a direct entry midwifery training programme which will deal with some of the problems and anomalies that the hon. Gentleman 417 has identified. It will allow students to follow a three-year course without first having to undertake nurse training and we hope that it will commence in the autumn of next year and will be well supported in the Mersey region.
There are also plans to extend professional development programmes for qualified midwives and to develop links with universities for an advanced diploma in midwifery course. Work is also beginning in Mersey on an examination of work loads and activity, linked to skill mix, to ensure the best utilisation of valuable midwifery resources. All these developments are to be welcomed and should serve to boost the morale of midwives in Mersey and aid their recruitment and retention.
418 We hope that we have demonstrated in the most practical way possible the high regard in which we hold the midwifery profession. Midwives' pay stands at its highest ever in real terms. The new grading structure is the biggest change in the grading and pay of midwives since 1948. The agreement was reached after very hard negotiations with the trade unions. It provides a structure capable of recognising and rewarding the exciting developments in the maternity services—
§ The motion having been made at Ten o'clock and the debate having continued for half an hour, MR. SPEAKER adjourned the debate without Question put, pursuant to the Standing Order.
§ Adjourned at half-past Ten o'clock.